Truth, truism, and perspective

We have been socialized to think that medical writings and teachings convey truth rather than simply conveying one of many perspectives.

According to Webster, a definition of truth is “an established or verified fact”. A truism is a statement, the truth of which appears obvious. The problem with these definitions, however, is that “facts” can be established in a variety of ways and people do not always agree on what is truth or what is a truism.

For example, a statement that has become a truism is that endogenous estrogen (the kind produced by the body) protects young women from heart disease. None of the research examining the levels of endogenous estrogen on heart disease, however, shows any relationship. Therefore, there are no established facts to back up this statement.

The nature of menopause has become highly controversial. It is important to know that information is always given from one perspective or another, rather than from some neutral stance. INORM makes no claims to neutrality, it is decidedly taking a health perspective. It is up to each of us to search for her own truth, to develop her own perspective. It is my hope that this site will provide useful information to aid in your search.

What is a health perspective?

A health perspective views menopause as a natural physiological process that is, in fact, health enhancing. During our reproductive years, we require high levels of fluctuating hormones in order to ovulate each month. After menopause, we enter a new stage of our lives. Since we no longer ovulate, we no longer need the high levels of hormones necessary for ovulation. Our ovaries do not fail us, however; they continue to produce the right amount of hormones for this new stage of our lives. Menopause is not a deficiency condition.

Another way of talking about this is simply to say that after menopause, our ovaries are “in retirement”. This is the term Sandra Coney uses in her book “The Menopause Industry”, p. 100. I like the “retirement” analogy because most retired people continue to work, they simply work at different things. Since they are no longer working to earn a living, they use their energy to serve their own interest and needs. I find that many midlife and older women have a higher energy level and are more self-directed than younger women. Margaret Mead refers to this higher energy level as PMZ, postmenopausal zest! Very often, women who have had the responsibility of raising a family and working outside the home, have little time to think of their own interests and needs. We now have the time to “seize the day!”

What is a medical perspective of menopause?

A medical perspective views menopause as a hormone deficiency condition that requires hormonal treatment. Proponents of this perspective provide information on chronic health problems and mortality rates in midlife and older women in ways that imply that they are caused by the hormonal changes that take place during the menopausal transition. This in turn has led to the widespread misconception that midlife and older women are at greater health risk than their male counterparts.

Note. Actually, most physicians do not hold the medical perspective on menopause. Gynecologists are much more likely than other specialists to view menopause as a deficiency condition. The medical view of menopause, however, has dominated the discourse.

What does the term “medicalization” mean?

Medicalization refers to changing a process or condition considered normal into one requiring medical intervention. The change begins with medical professionals but must be accepted by the community at large in order to be considered medicalized.

The medicalization of childbirth in the US is a good example. Attempts to medicalize began in earnest in the early part of this century and by the 1940s, the need for medical intervention during childbirth was accepted by the community at large. Today, 99% of US births occur in hospitals and interventions during labor and birthing process are the norm.

There are ongoing attempts to reclaim childbirth as a normal process with some small successes. For example, physicians attended 92.2% of all births in 1996; midwives 6.5%. In 1975, the rates were 98.4% and 0.6%. The US is the dubious leader in the medicalization of childbirth, menopause, and women’s bodies in general.

Once something has become medicalized, it difficult reclaim it. Although abundant research shows that both mothers and babies do better with experienced midwives in a home or free-standing birth center, this option is simply not available for the majority of US women. Barbara Harper, a childbirth activist in the US, was reported to Children and Family Services by her former physician for child endangerment. Her transgression: choosing to give birth at home.

For more on this, see Reclaiming Birth, a book by Margot Edwards and Mary Waldorf. These authors were part of my inspiration to reclaim menopause. I also recommend Barbara Harper’s videoGentle Birth Choices for women interested in childbirth.

History of attempts to medicalize menopause

Although the emphasis on menopause as an estrogen deficiency condition is relatively recent, there is a long history of medical professionals attributing ill health (1) and even characteristics considered undesirable for women to their sexual and reproductive hormones or organs. Anger, depression, or unreasonableness in women have been attributed to either “that time of the month” or “that time in their lives” (the menopause) while these same feelings in men have been either considered acceptable male behavior or simply an appropriate response to circumstances.

The term “hysterical” originally came from the belief that this condition was somehow due to a woman’s uterus and many women in the last century had hysterectomies as a way of treating a variety of psychological problems. Weir Mitchell, a well-known 19th century physician (2), defined women’s natural state as basically unhealthy and prescribed “rest cures”. It was believed by some that if women studied too much, their reproductive organs would not develop properly, resulting in lower fertility. This connection was most likely made because educated women had fewer children and some even chose not to have any!

The current notion that menopause is a deficiency disease requiring long term, some say life-long, hormones can be almost exclusively traced back to one man, Robert Wilson, the founder of the Wilson Foundation (3). It is important to note that this foundation was heavily funded by the U.S. pharmaceutical industry. Before his writings, women who experienced distress due to hormonal changes typically took estrogen for a short period of time to alleviate the distress. This would be similar to a woman taking antacids to relieve heartburn and indigestion caused by rapidly changing hormones in the early months of her pregnancy. Neither menopause nor pregnancy are diseases but, due to hormonal changes, both can cause distress for a period of time.

Robert Wilson began publishing articles (4) in medical journals in the early 1960s, constructing menopause as a deficiency disease similar to diabetes. He encouraged doctors to prescribe estrogen for women “til the grave”. Here are Wilson’s own words: “She has outlived her ovaries and therefore her biological usefulness.” He countered the argument that taking estrogen pills is unnatural by asserting that since modern medicine has lengthened the life span, a longer life is “an unnatural burden” to women without estrogen.

In his book, Feminine Forever (5), a popularized version of his beliefs, Wilson wrote “… no woman can be sure of escaping the horror of this living decay. … even the most valiant woman can no longer hide the fact that she is, in effect, no longer a woman but a neuter”. (p43) He capitalized on the newly energized women’s movement by arguing that preventing menopause meant, that “for the first time in history, women may share the promise of tomorrow as biological equals of men.” I felt saddened when I recently read this misogynist and terribly patronizing book, because I knew that it would not have had the the effect on women it did if we did not already live in a sexist and ageist society.

Just one year after Feminine Forever was published, Wilson’s ideas were conveyed in a gynecology textbook (6) as if they were coming from midlife women themselves: “The patient [a menopausal woman] may feel that the end of her useful life has come, that now she is old, that she has lost her appeal as a woman, and that nothing is left to her.”

Our society continues to be sexist and ageist, and while these writings sound overtly misogynist to us today, biases in medical literature persist, albeit more covertly. Physicians continue to see our bodies as basically unhealthy. While we are no longer thought of as neuters, we are considered either diseased or at high risk for a growing list of diseases due to our “hormonal deficiencies”. Thenand now we can only be “normal” if we take estrogen.

Here are some excerpts from more recent medical writings on menopause and menopausal women:

1990 P.A. van Keep (7), a gynecologist and co-founder of the North American Menopause Society: “Robert Wilson rendered women aged over 45 a great service.” “… his imagination put things into perspective”.

1990 Wulf H. Utian (8), a gynecologist and the other co-founder of the North American Menopause Society: “The climateric, one syndrome occuring over a period of time, has potentially lethal effects, notably coronary heart disease and complications of osteroporotic fractures”

1990 Saul Lerner (9) “… I am putting my patients on hormones not because I consider the women as having an illness but rather because I hope to prevent future problems.”

1994 Rogerio Lobo, M.D. (10) “However, although menopause is a natural event, while the age of menopause has not changed with time, life expectancy has markedly increased. Therefore it is perhaps not ‘natural’ for women to be living longer” (pg 427)

1994 Roger P. Smith (11). “More and more, we are coming to view menopause as not the “natural process” we once considered it, but rather as an organ failure.”

And finally, the authors of the latest edition of a leading textbook (12) for those studying to be gynecologists, have moved the chapter on menopause from normal endocrinology to abnormal!

References

(1) For more information on the medical views of women from a historical perspective see:

B. Ehrenreich and D. English, For Her Own Good: 150 Years of the Experts’ Advice to women. (New York: Anchor, 1979):

R. Hubbard, The Politics of Women’s Biology (New Brunswick, J.J.: Rutger University Press, 1990).

Kary L. Moss (Ed) Man-made medicine: Women’s health, public policy, and reform.

Fee, Elizabeth; Science and the Woman Problem: Historical Perspectives, in Sex Differences: Social and Biological Perspectives,(Ed) M. S. Teitelbaum (New York: Anchor/Doubleday, 1976), 175-223.

(2) Charlotte Perkins Gilman, one of Mitchell’s patients and critics wrote “The Yellow Wallpaper”, a fictionalized account of her experience.

(3) For a discussion of Robert Wilson’s connection with the pharmaceutical companies: Barbara Seaman, Women and the crisis in hormones., pp351-2.

(4) Examples of Wilson’s writings: Journal of the American Geriatric Society 11, 347-62; Apr 63; Western J of Ob Gyn 1963; 71, 110-2. More information about Wilson’s writings.

(5) Robert Wilson, Feminine Forever, 1966, M. Evans & Co., N.Y.

(6) Brewer J.I. and deCosta E.J. 1967, p229 Textbook of Gynecology, 4th ed. Baltimore: Williams & Wilkins.

(7) P. A. van Keep, M.D. Maturitas, 12; 1990 p163-4. The History and Rationale of Hormone Replacement Therapy.

(8) Wulf Utian, M.D. Annals of the New York Academy of Science 1990 592: p125.

(9) Saul Lerner, M.D. Annals of the New York Academy of Science #592 p192.

(10) Rogerio Lobo, M.D. Treatment of the postmenopausal woman: Basic and Clinical Aspects. New York: Raven, 1994 p427

(11) Roger P. Smith. Current opinion in obstetrics and gynecology1994; 6: 495-98. Modern menopause management

(12) Mishell’s textbook of infertility, contraception, and reproductive endocrinology. Blackwell Science (1997)

Is menopause currently medicalized?

You may be surprised to learn that my answer is “No!” In order for a normal process to become a medical condition in any community, most people in that community must agree that it is. Just because medical textbooks and articles are redefining menopause as a deficiency condition doesn’t mean that most women and perhaps most physicians accept this perspective.

There is a perception out there that most midlife and older women take hormones, thereby accepting the medicalization of menopause. While it is hard to get the exact percentage of women taking them, a recent report of the U.S. Nurses’ Health Study (NHS) found that only 15% of all nurses who had completed their menopause currently took hormones. Moreover, the majority of these women did not experience a natural menopause but had had their ovaries removed. Women who had had their ovaries removed are not, in fact, being treated for the natural process of menopause but, instead for an iatrogenic condition, that is, a condition resulting from surgical intervention. (The assumption that menopause and the surgical removal of a woman’s ovaries result in identical conditions is simply not true.)

There are many articles published, some in medical journals, countering the medical perspective and questioning the need for long term hormone use for healthy midlife and older women. These articles, however, do not get the same media coverage as those written by proponents of the medical model See Suggested readingsfor a list.

The NHS report can be found in the New England J Medicine 11/20/97.

What’s wrong with medicalizing menopause?

Medicalizing menopause defines the bodies of midlife and older women as deficient and at high risk for disease. This notion of deficiency filters through society at large. An egregious example of this is found in Crain, a Chicago business newspaper, which published an article with the caption: “The executive suite faces menopause.” Although women executives say menopause doesn’t affect their job performance, it has become a corporate issue. Marie Lugano, president of the American Menopause Foundation in New York is quoted: “A 45-year old executive with a heart condition is going to cost a company.” One quick look at the mortality data, however, shows that a 45 year old man is about four times more likely to die of heart disease than a 45 year old woman. We now have the first major wave of women executives who are in their 40’s and early 50’s. The problem these women face is not menopause but sex discrimination, of which this is a prime example.

Medicalizing menopause shapes the research questions. The HERS trial (Heart and Estrogen/progestin Replacement Study) is said to be the female counterpart to MRFIT (Multiple Risk Factors Inventory Trial). Both are randomized clinical trials designed to study the effects of intervention on risk for ‘heart’ disease. However, MRFIT, as the name implies, studied the effects of multiple risk factors such as smoking cessation, diet and exercise in men while HERS only studied the effects of hormone use in women. In fact, estrogen has now become the most researched drug for heart disease prevention in women. The assumption made is that heart disease in women is due primarily to our “failed” ovaries while heart disease in men is due to their lifestyle. How can we learn the best strategies to reduce our risk of heart disease if other strategies are not well researched?

Medicalizing menopause allows for the acceptance of hormone use as a primary prevention strategy with a lower standard of proof than other primary prevention strategies. For example, most drug interventions require proof of efficacy from large scale randomized clinical trials (considered the ‘gold standard’ in medical research) before they are widely used. Although many observational studies show a beneficial effect on heart disease from estrogen use, the only large scale randomized clinical trail, the HERS trial, a study of women with established heart disease, showed no benefit. Before the results of the HERS trial were published, Elizabeth Barrett-Connor commented on the lower standard of proof: “Some think the results are sufficiently persuasive to recommend estrogen to nearly all postmenopausal women. If applied, this would be the first time in history that a drug has been recommended to prevent disease in an entire population defined only by age and sex.” (Quoted in Fertility and Sterility 1994; 62 (Suppl 2) 127S-32S)

Medicalizing menopause allows risk-benefit analysis to be used. Simply put, risk-benefit analyses are used to determine if the risk of a particular drug is worth the benefit. For example, if you have breast cancer, you would probably choose to take a cancer fighting drug even though you know the drug may make you very sick and may possibly have serious adverse effects like liver damage. Why? Because you weighed the risk with the benefits. If research showed that taking this drug would increase your chance of surviving breast cancer, this benefit would be worth the risks. Now physicians are applying risk-benefit analysis on healthy midlife and older women. We are urged to accept the risks of hormone use, including an increased risk of breast cancer. Why? We don’t have a disease. The evidence is not convincing that menopause increases our risk for heart disease nor is it convincing that taking hormones will reduce our risk. In fact, there is much evidence that all the diseases associated with menopause are primarily due to factors other than hormones.

Medicalizing menopause encourages experimentation to be used on healthy midlife women. The vast majority of women do not take long-term hormones. Many choose not to take them for the simple reason that they do not think they need them. There are other women, however, who would take long term hormones if the adverse effects were reduced. Some physicians are altering the types and doses of hormones in attempts to reduce these adverse effects while other physicians are encouraging midlife women to take testosterone along with their estrogen and progestin. After the HERS result showing no beneficial effect on heart disease risk, suggestions have been made to try other hormonal regimens. According to a recent study by the Pharmaceutical Research and Manufacturers of America, 372 new medicines are being developed to ‘treat’ menopause. (Cited in “Midlife and Menopause: Uncharted Territories for Baby Boomer Women” by Judith G. Gonyea, in “Generations, Spring, 1998)

Medicalizing menopause may also result in serious consequences to men’s health as well. The hypothesis that endogenous estrogen protects younger women, used to explain the gender gap in heart disease, may hamper the long term, and as yet unresolved investigation of why men die of heart disease at a younger age and a higher rate than women!

Age-adjusted death rates and M:F ratios for the top 15 causes of death, USA

Disease Male Female Ratio M/F
Diseases of the heart (390-398, 402, 404-429*) 195.1 103.8 1.88
   Ischemic Heart Disease (410-414) 1334.8 65.7 2.04
Malignant neoplasms (cancer) (140-208) 162.6 111.8 1.45
Cerebrovascular diseases (stroke) (430-438) 28.6 24.2 1.18
Accidents and adverse effects (E800-E949) 43.1 16.4 2.63
Chronic obstructive pulmonary diseases (490-496) 26.4 15.5 1.70
Pneumonia and influenza (480-487) 16.5 9.8 1.68
Diabetes mellitus (250) 12.7 11.1 1.14
Suicide (E950-E959) 18.4 4.3 4.28
Chronic liver disease & cirrhosis (571) 11.6 4.8 2.42
HIV infection (AIDS) (042-044) 1992 data 4.36
Homicide and legal intervention (E960-E978) 16.7 4.2 4.0
Nephritis, nephrotic syndrome, & nephrosis (580-589) 5.6 3.6 1.6
Septicemia (038) 4.6 3.6 1.3
Atherosclerosis (440) 2.8 2.1 1.3
Conditions originated in the perinatal period (760-779) 6.6 5.4 1.2

These 15 causes of death accounted for approximately 86% of all deaths in the US in 1992. Rates are given per 100,000.

*Numbers in parentheses refer to the 9th International Classification of Disease (ICD-9).

Source: The National Center for Health Statistics, Vital Statistics of the United States, Vol II, Mortality, Part A. Washington: Public Health Service, 1996. (Table 3)

Personal health decision making

We make personal health decisions every day. Most of us know, in a general sense, what foods are good for us and that we need to exercise, reduce stress in our lives, and keep out of harm’s way. If you are a midlife or older woman taking the time and effort to search for health information on this web site, it is very likely that you are much more health conscious than the average person.

Many midlife women are being told by proponents of the medical perspective on menopause that the most important health decision they will need to make is whether or not to take hormones. While acknowledging the decision should be made by the woman herself, information is typically given from the medical perspective and women are being urged to take hormones.

As a proponent of the health perspective, I feel that the above question is shaped by the medicalization of menopause. In my opinion, what women really want to know is how we can best maintain our health, reduce our risk of disease, and improve our overall quality of life. There are many strategies we can use to accomplish these goals and the more we know about them, the more likely we will choose those strategies that suit us best.

It is my responsibility as a professional health educator, to provide you with accurate information from an acknowledged health perspective. I will do this by clarifying concepts, providing critiques and summaries of articles relating to midlife and older women, and inviting users of this site to share information.

It is the responsibility of medical professionals to provide accurate information from the perspective they hold. (Remember, medical professionals do not necessarily hold a medical perspective on menopause). They also need to inform women that there continues to be controversy surrounding the nature of menopause and the use of hormones.

It is the responsibility of all of us as consumers of information to learn what we can and then take responsibility for our decision making. You may have read that we should share decision-making with our medical care providers. It is important to share information with them but the decisions we make must be ours alone. After all, we are the ones that derive the benefits or incur the risks of our decisions. We have the right and the obligation to hold medical/health professionals accountable for misleading or inaccurate information.

Guide to decision making

First of all, it is important to clarify your perspective. Do you lean toward a health perspective or a medical one?

If you are already taking hormones, ask yourself “Why?” If it is for the transitional period and you have a lot a distress, taking hormones to reduce this distress may be a good decision, especially if you do not have side effects from them. Some women feel better on hormones, others feel worse. Even if you feel better on hormones, you may still not want to take them for a long period of time because of the adverse effects, especially the increased risk of breast cancer. Susan Love, in her book “Susan Love’s Hormone Book” suggests weaning yourself off them after a while.

If you are taking hormones to maintain your health or reduce your risk of chronic diseases like heart disease or osteoporosis, be aware of the biases in the studies showing beneficial effects. Since you will most likely be advised to take them for many years, compare hormone strategies with other strategies. It is best to get information from a variety of sources. Be aware that much of the information in the public eye originates from pharmaceutical companies. Try to identify the perspective of the sources of information so that you can more easily evaluate them. For example, if you read a pamphlet on osteoporosis, look on the back to see who produced it.

Remember, you are the one who will reap the benefit or be at risk from any health decision you make.